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ORIGINAL ARTICLE
KEYWORDS
Bladder tumor;
Partial cystectomy;
Urothelial carcinoma
Abstract Radical cystectomy has remained the gold standard for recurrent superficial or
muscle invasive bladder tumor. However, partial cystectomy still has a role in those who reject
or have contraindications for radical cystectomy. In this study, we sought to identify predictors
of bladder recurrence and overall survival after simple partial cystectomy. We included 27 patients with bladder tumor who received simple partial cystectomy without pelvic lymph node
dissection between March 2000 and September 2013. Adjuvant chemotherapy or radiation
therapy was prescribed according to the pathological results. Parameters were compared on
the basis of bladder recurrence and overall survival. During a mean follow-up time of
39 months, five patients (18.5%) experienced bladder recurrence. An older age, a higher pathological stage, positive surgical margins, and distant metastases were significant predictors of
overall survival (p Z 0.031, p Z 0.001, p Z 0.001, and p Z 0.011, respectively). Meanwhile,
previous bladder instillation and positive surgical margins were significant predictors of
bladder recurrence (p Z 0.026 and p Z 0.027, respectively). The rate of consecutive distant
metastases (33.3%) was almost twice the rate of bladder recurrence (18.5%), and six patients
developed consecutive distant metastases without first experiencing bladder recurrence. In
patients who received a simple partial cystectomy as an alternative treatment, previous
bladder instillation and positive surgical margins were significant predictors of bladder recurrence. Patients with an older age, positive surgical margins, and consecutive distant metastases had worse overall survival. Partial cystectomy with routine lymph node dissection may be a
better option for achieving favorable long-term outcomes.
192
Introduction
Urothelial carcinoma of the urinary bladder is strongly
associated with environmental factors and age. The incidence and prevalence rates increase with age, peaking in
the 8th decade of life [1,2]. In the United States in 2007,
bladder urothelial carcinoma accounted for 7% of all cancers [1]. In addition to its high prevalence, bladder cancer
is fatal, accounting for 3% of all cancer deaths in the United
States in 2007. However, due to advancements in treatment
strategies and modalities, bladder cancer mortality
decreased by 5% between 1990 and 2004, despite a
continuous rise in the incidence of the disease [1].
Radical cystectomy is one of the main treatment options
for localized muscle invasive bladder urothelial carcinoma
and select nonmuscle invasive disease. However, along with
cancer control, radical cystectomy also results in some
degree of reduction in the quality of life; it impacts
continence, body image, and potency. These consequences
make bladder preservation during treatment an important
goal, for both patients and surgeons, in advanced bladder
cancer cases.
A partial cystectomy with pelvic lymph node dissection
can be reserved for select patients with a solitary lesion for
whom radical cystectomy is otherwise contraindicated and
a sufficient margin can be obtained. Some previous studies
noted the comparable prognosis of radical cystectomy and
partial cystectomy with adequate patient selection [3,4].
In this study, we analyzed patients who underwent
simple partial cystectomy without pelvic lymph node
dissection with the aim of identifying predictors of bladder
cancer recurrence and overall survival in this population.
Results
Patient characteristics are listed in Table 1. The mean age
of patients who underwent partial cystectomy was
70.6 years (range 49e90 years). The mean follow-up time
after partial cystectomy was 39.0 months. The patients
were predominantly male, with a male to female ratio of
5.8.
Overall, 63% (17) of patients had pathological Stage T1
or Stage T2 disease, while Stage T3 and Stage T4 disease
accounted for 33.3% (9) and 3.7% (1) of cases, respectively.
The most common tumor histology was infiltrating carcinoma (74%); other histologies included papillary (14.8%),
sarcomatoid (7.4%), and poorly differentiated types (3.7%).
In terms of pathological grade, high-grade tumors accounted for 88.9% of all cases.
Fourteen (51.9%) patients had superficial bladder tumors
for which they had previously received TUR-BT. Among
these 14 patients, 11 (40.7%) had undergone TUR-BT once
and three had received TUR-BT at least twice. Previous
intravesical therapies including epirubicin, mitomycin, and
BCG instillation were prescribed according to individual
status in keeping with the National Comprehensive Cancer
Network guidelines [5]. Pathological specimen examination
showed that four (14.8%) patients had residual cancer at
the surgical margin and 23 (85.2%) patients had clear surgical margins.
During a mean follow up of 39.0 39.0 months, five
(18.5%) patients experienced tumor recurrence in the
bladder, nine (33.3%) patients developed distant metastasis
postsurgically, and 10 (37%) patients died. Results of the
univariate analysis performed using KaplaneMeier survival
curves for overall survival are shown in Table 2. Significant
predictors of overall survival in patients who received
partial cystectomy were: age > 70 years, a higher
Patient characteristics.
(49e90)
(3.13e148.4)
(20.7e34.4)
193
Table 2
survival.
Sex
Female
4
Male
23
Age (y)*
< 70
13
70
14
Body mass index (kg/m2)
24
12
> 24
13
Pathological T stage*
1
10
2
7
3
9
4
1
Tumor size (cm)
<2
6
2 and < 4
12
4
9
Histology
Papillary
4
Infiltrating
20
Others
3
(sarcomatoid and
poorly
differentiated)
Pathological grade
Low
3
High
24
ASA score
1
1
2
13
3
13
Previous TUR-BT
No
13
Yes
14
Number of
previous TUR-BTs
0
13
1
11
2
3
Previous intravesical instillation
No
24
Yes
3
Surgical margin*
Negative
23
Positive
4
Bladder recurrence
No
22
Yes
5
Distant metastasis*
No
18
Yes
9
27.8 10
88.0 16
2
8
0.121
118.7 18
47.2 13
2
8
0.031*
4
4
0.670
94.8 11
26.0 7
91.1 25
4.6
2
4
3
1
0.001*
57.8 10
65.6 15
81.9 23
1
5
4
0.870
63.8 12
93.5 18
82.0 15
3
6
1
0.539
88.3 20
75.3 16
1
9
0.312
0
4
6
0.202
103.2 18
33.2 5.4
67.2 15
82.4 20
5
5
0.875
67.2 15
89.4 20
16.1 15
5
4
1
0.440
10
0
0.582
93.0 16
16.5 8
7
3
0.001*
92.4 16
44.9 23
7
3
0.154
102.2 18
37.9 14
4
6
0.011*
94.7 19.9
57.1 12.3
*p < 0.05.
ASA score Z American Society of Anesthesiologists score; TURBT Z transurethral resection of bladder tumors.
194
Sex
Female
4
Male
23
Age (y)
< 70
13
70
14
Body mass index (kg/m2)
24
12
> 24
13
Pathological T stage
1
10
2
7
3
9
4
1
Tumor size (cm)
<2
6
2 and < 4
12
4 cm
9
Histology
Papillary
4
Infiltrating
20
Others
3
(sarcomatoid
and poorly
differentiated)
Pathological grade
Low
3
High
24
ASA score
1
1
2
13
3
13
Previous TUR-BT
No
13
Yes
14
No. of previous TUR-BTs
0
13
1
11
2
3
Previous
intravesical
instillation*
No
24
Yes
3
Surgical margin*
Negative
23
Positive
4
Mean
No. of
recurrence-free deaths
time (mo)
0
5
0.346
126.2
87.7
2
3
0.606
124.4
69.4
2
3
0.637
90.6
34.96
114.1
2
1
2
0
0.956
57.8
93.6
116.3
1
2
2
0.956
68.3
118.7
1
4
0
0.539
0
5
0.393
0
3
2
0.774
95.1
116.5
2
3
0.700
95.1
135.2
8.4
2
1
2
0.078
129.7
8.1
10
0
0.026*
129.5
5.3
3
2
0.027*
*p < 0.05.
ASA score Z American Society of Anesthesiologists score; TURBT Z transurethral resection of bladder tumors.
Discussion
Ninety percent of urinary bladder cancers are urothelial
cell carcinomas [6], with muscle invasive disease accounting for 80% of urothelial tumors at initial presentation.
Radical cystectomy remains the most frequently utilized
surgical intervention for clinical Stage T2 and Stage T3
bladder urothelial carcinoma without lymph node or distant
metastases. Cystectomy may also be indicated for select
superficial bladder tumors, for example, recurrent pT1
high-grade tumors.
For patients in whom radical cystectomy is indicated,
but who wish to preserve the urinary bladder, alternative
treatments include radical TUR-BT, partial cystectomy, and
neoadjuvant concomitant chemoradiotherapy. Partial cystectomy plays a role in select patients with appropriately
located solitary tumors and resectable margins. A standard
partial cystectomy should include bilateral pelvic lymph
node dissection to confirm lymph node stage.
Previous studies have reported on prognosis with standard
partial cystectomy, along with predictors of survival or
recurrence. Holzbeierlein and colleagues [3] reviewed the
cases of 58 select patients who underwent partial cystectomy
with pelvic lymph node dissection for bladder urothelial carcinoma and were followed up for 33 months. They reported
that partial cystectomy with pelvic lymph node dissection can
result in comparable outcomes in specifically selected patients. In addition, concomitant carcinoma in situ and lymph
node metastasis were found to be predictors of advanced
recurrence. Smaldone and colleagues [4] reviewed the cases
of 25 patients with primary solitary T2 or high-grade T1 tumors
who received preoperative radiation for 5 days and a single
dose of intraoperative intravesical chemotherapy followed by
partial cystectomy with pelvic lymph node dissection. Over a
follow-up period of 11 years, the cancer-specific 5-year survival was 84%. To the best of our knowledge, the role and
prognosis of simple partial cystectomy have not been discussed in previous studies.
In this study, we aimed to identify prognostic predictors
for patients who underwent a simple partial cystectomy.
During a mean follow-up time of 39 months, the bladder
tumor recurrence rate was 18.5%, with an overall survival
rate of 63%. The significant predictors of poor overall survival were: age > 70 years, a higher T stage, positive surgical margins, and consecutive distant metastases. These
predictors were similar to the prognostic factors of patients
who underwent a radical cystectomy [7e9]. In addition,
previous intravesical bladder instillation and positive surgical margins were significant predictors of bladder tumor
recurrence. This can be explained by the fact that patients
for whom intravesical instillation was indicated had a T1
high-grade tumor, coexisting carcinoma in situ, or a
recurrent bladder tumor. These patients are at high risk for
bladder tumor recurrence after partial cystectomy. Patients with positive surgical margins after a partial cystectomy also had a high probability of bladder tumor
recurrence despite adjuvant chemotherapy or radiation
therapy. Thus, a more aggressive follow up is important in
these patients. Although not significant, patients with a
history of multiple previous TUR-BTs (>2) were more likely
to have bladder tumor recurrence (p Z 0.078).
Conclusion
For patients who underwent simple partial cystectomy as
an alternative treatment, previous bladder instillation (due
to previous high-grade or carcinoma in situ tumors) and
positive surgical margins were significant predictors of
bladder tumor recurrence. Patients aged > 70 years, and
those with positive surgical margins and consecutive distant
metastases, had worse overall survival.
With adequate patient selection and proper postoperative follow up, simple partial cystectomy without
pelvic lymph node dissection could provide a favorable
prognosis for local bladder tumor recurrence. However, the
lymph node or distant metastasis rate appeared relatively
higher in our patients than in patients who received partial
cystectomy with pelvic lymph node dissection in other reported case series. A possible reason for the variation in
results may be that potential lymph node metastases were
missed on preoperative images. For patients who are eligible
195
for partial cystectomy, simultaneous lymph node dissection
may result in more favorable long-term outcomes in terms of
overall survival or distant metastases, even in those without
suspected lymph node metastasis.
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